Should patients with short life expectancy be denied surgical care?

For decades, life expectancy was used as an exclusion criteria for spine surgery. It was part of the spine literature that if a patient was expected to live for less than three months, they should not have surgery.

Initially, the underpinning argument was concerned with recovery times. The surgical profession said that if the patient is going to spend most of their remaining life recovering from surgery, it’s probably not worth doing it.

There was also a cost factor. In the past 10 to 15 years health economics has emerged as an important decision maker. I did a master's in health economics at London School of Economics at the beginning of my career, so it’s an area I’m interested in. I also think it’s a field we should bring into the AO Spine Knowledge Forums because if surgeons aren’t sitting around that table, someone else will make the decisions for us. Someone else will say "Okay we have this new fancy treatment, but your patient is dying so it’s not worth it."

So, in the past, life expectancy was a key metric because the surgical recovery time was thought to be too long, and the health economics were unfavorable. What has changed over the last 10 years is the development of minimally invasive surgeries and other advances that leave a smaller surgical footprint on the patient.

There are some small interventions we can make. Yes, it’s still spine surgery—it’s not taking a pill—but often these patients can be discharged in 24 or 48 hours, and they can go back home. That is worth so much to a patient, as opposed to being bedridden and transferred to a hospice.

What is the scientific basis for excluding patients from surgery?

This question has been a continuum of interest for me, which came into sharp focus when I was caring for these patients with three months or less to live. It was a firm criteria—if they had less than three months, forget it. And we were teaching this. Yet I did not know how long the patient was going to live. So, I would call the oncologist, and they could not give a definitive answer either.

That is the central issue. No-one really knows how long this patient will live. We are making a decision on operating, but we can’t predict survival. I reached a point where I felt we had to do something about it. In our field, if we cannot prove something in a sound, scientific way, then it should be challenged. We have our impressions, and that’s normal, but impressions are not facts.

We decided to study this criteria rigorously through a cohort of international patients, and in fact our hypothesis turned out to be true. Surgery improved quality of life just as much for patients regardless of whether they had a short versus a long life expectancy. If we believe—and I do—that quality of life is the most important outcome measure, then life expectancy is irrelevant because the improvement was irrespective of the length of life.

Imagine the implications for the patient. Imagine being denied surgical care because someone believes (with the best of intentions) that you’re not going to make it past three months. Then we go on to survive for longer, and we suffer needlessly. It’s terrible.
If we cannot predict life expectancy, then we should move away from it altogether. As a scientific field we should not have an inclusion—or more specifically an exclusion—criteria based on something we cannot accurately measure.

Impacts to quality of life

This research has implications for thousands of patients. Bone is a frequent site of metastasis in patients with cancer, and patients with cancer are living longer and longer because our colleagues in oncology have changed the paradigm. There have been enormous advances in the molecular world and the field of personalized treatment.

In lung cancer, for instance, when I started practice 10 years ago, some of my colleagues would not operate on a long cancer patient because their prognosis was so poor. Now they have found some molecular targets, and lung cancer patients are surviving for up to three years.

That is great for the patient, but unfortunately it also gives them more time to develop metastases to the spine. This has a profound impact on patients’ lives. In addition to having to cope with the pain, they may also become paralyzed and lose control of their bowel, bladder, and sexual function. If there is something we can offer to improve these patients’ quality of life, then I believe we should offer it. Or at the very least it should be part of the discussion.

A metric, but not the only metric

As part of the study, we asked one simple question of all patients: Are you satisfied with treatment so far? Essentially, if they knew what would happen - how surgery would help or not help—would they still have chosen to have the surgery?

Because unfortunately we don’t help everyone. There are some patients with short life expectancy who have the surgery and experience complications, or develop a wound infection, and spend two months in hospital when they only had three months left to live. We didn’t help that patient. This is where personalized medicine becomes so important, because we need to find out, why did this patient not do so well? Why did I not predict this? How can I improve my decision making?

However, when we asked patients if they were satisfied with their treatments, for the vast majority satisfaction rates were through the roof. Most said they were very happy with the treatment they received, and they felt cared for.

A lot of patients, when you sign off on them and say, "No I’m not going to operate because you’re too sick", they really feel like you’re letting them down. And we are. I wouldn’t say it’s a placebo effect but patients who feel cared for record higher rates of satisfaction with their treatment.

I hope our research demonstrates that life expectancy is part of the answer to how aggressive we should be from a surgical viewpoint, but not a definitive answer to "Am I operating, yes or no?"

There’s no other platform like the AO Spine Knowledge Forums to answer these questions. They provide a non-competitive environment, and the world is represented around that table. We can gather a lot of data quickly because we can enroll so many patients.

This would not be possible if one Nicolas Dea in Vancouver wanted to answer that question. We know now that single institution work is not the way to go, especially with rare diseases. We need a collaborative, multidisciplinary, international approach and this is what the AO Spine Knowledge Forum provides. Through the AO Spine Knowledge Forums, we will be able to answer these questions, until we find new ones.

References and further reading:

1. Dea N, Versteeg AL, Sahgal A, et al. Metastatic Spine Disease: Should Patients with Short Life Expectancy Be Denied Surgical Care? An International Retrospective Cohort Study. Neurosurgery. 2020;87(2): 303-311.

Read more about the AO Spine Knowledge Forum Tumor, their studies, and outcomes here.